Skip to Content
by HealthDay staff

U.S. to Tighten Access to Certain Narcotic Painkillers

Drugs containing hydrocodone, which include Vicodin, would be affected
THURSDAY, Aug. 21, 2014 (HealthDay News) -- The U.S. Drug Enforcement Administration (DEA) is going ahead with tough new controls on painkillers containing hydrocodone, which has been tied to a surge in dangerous addictions across the United States.
The new restrictions would cover prescription narcotic drugs such as Vicodin, Lortab and their generic equivalents, putting them in the same regulatory class as painkillers such as Oxycontin, Percocet and codeine. Patients will now only have access to a three-month supply of the drug and will have to see a doctor to get any refills.
The new rules, posted online by the DEA on Thursday, come more than 18 months after a U.S. Food and Drug Administration advisory panel met to discuss the fate of painkillers containing hydrocodone. That 2013 meeting followed the DEA's request for an FDA panel review on the issue. The painkillers were previously classified as Schedule III drugs, but the DEA wanted them placed under the more restrictive Schedule II designation.
"Almost seven million Americans abuse controlled-substance prescription medications, including opioid painkillers, resulting in more deaths from prescription drug overdoses than auto accidents," DEA Administrator Michele Leonhart said Thursday in a news release. "Today's action recognizes that these products are some of the most addictive and potentially dangerous prescription medications available."
One expert applauded the move toward stricter oversight.
"Moving hydrocodone-combination products into DEA Schedule II for controlled substances will have several important effects," said addiction psychiatrist Dr. Eric Collins, physician-in-chief at Silver Hill Hospital in New Canaan, Conn. "It will relatively rapidly reduce the now very easy availability of hydrocodone -- this will help mitigate the rapid growth we've seen in the last 20 years in addiction to opioid [narcotic] pain relievers and heroin."
Collins also believes the move will "reduce both the number of new initiates to opioid use and the number of accidental and intentional overdose deaths. This change is both most welcome and long overdue."
Janina Kean, president and CEO of High Watch Recovery Center in Kent, Conn., said she thinks the DEA's new regulations "will have more of an impact on the adult population or individuals inappropriately prescribed very strong narcotics for mild operative procedures, than it will for the nation's adolescents, a population where 96 percent of substance abuse starts."
The new regulations, Kean added, should reduce the availability of "prescription drugs developed for excruciating pain from being used to treat much less severe ailments like dental procedures or minor surgery."
But she foresees potential problems with the stricter regulations. "With access to drugs like Vicodin and Percocet limited by the regulations and harder to obtain, we may end up seeing a trend of [teens] skipping the pills and going straight to heroin," she said.
The regulation of prescription painkillers has been a contentious issue.
Supporters of a move to a more restrictive Schedule II status pointed to tragic deaths and suicides that have been the result of misuse of these prescription drugs.
But, opponents of the tougher classification fear that tightening access to the drugs would mean that people who really need them to ease pain would not be able to get them.
Few people dispute the fact that too many of these opioid drugs are too widely available, even though the pharmaceutical industry has recently developed "abuse-resistant" formulations to help fight misuse.
Overall, some 22 million Americans have misused prescription painkillers of one kind or another since 2002, according to a report released by the U.S. Substance Abuse and Mental Health Services Administration. The agency noted that prescription painkillers now rank only behind marijuana as a drug of abuse in the United States.
More information
Visit the U.S. National Library of Medicine ( ) for more on prescription drug abuse.
SOURCES: Eric D. Collins, M.D., physician-in-chief, Silver Hill Hospital, New Canaan, Conn.; Janina Kean, president and CEO, High Watch Recovery Center, Kent, Conn.; Aug. 21, 2014, news release, U.S. Drug Enforcement Administration
by HealthDay staff

Air in U.S. Cities Getting Cleaner, EPA Says

Levels of many toxins, pollutants have been lowered since 1990, according to the agency
THURSDAY, Aug. 21, 2014 (HealthDay News) -- The air in American cities is getting safer to breathe, the U.S. Environmental Protection Agency reported Thursday.
Significant progress has been made in reducing levels of harmful substances in urban air in recent decades, the agency said in a news release.
Since 1990, there has been a nearly 60 percent reduction in mercury from human sources such as coal-fired plants, a 66 percent decline in benzene, and an 84 percent fall in lead, which harms brain development in children.
About 3 million tons per year of pollutants such as particulate matter and sulfur dioxide have also been reduced from cars and trucks, the EPA said.
There has been a reduction of about 1.5 million tons per year of hazardous air pollutants such as arsenic, benzene, lead and nickel from stationary sources, and another reduction of 1.5 million tons per year of these pollutants from mobile sources, according to the agency.
These pollutants are known or suspected to cause cancer and can harm people's immune, respiratory, neurological, reproductive and developmental systems, the EPA said.
The agency's report is the final of two required under the Clean Air Act to inform Congress of progress in reducing public health risks from urban air pollution.
"This report gives everyone fighting for clean air a lot to be proud of because for more than 40 years we have been protecting Americans -- preventing illness and improving our quality of life by cutting air pollution -- all while the economy has more than tripled," EPA Administrator Gina McCarthy said in the news release.
"But we know our work is not done yet. At the core of EPA's mission is the pursuit of environmental justice -- striving for clean air, water and healthy land for every American; and we are committed to reducing remaining pollution, especially in low-income neighborhoods," she added.
More information
The U.S. Centers for Disease Control and Prevention has more about air quality and health ( ).
SOURCE: U.S. Environmental Protection Agency, news release, Aug. 21, 2014
by HealthDay staff

Both U.S. Health-Care Workers Infected With Ebola Released From Hospital

Though still weak, they're expected to continue to recover and pose no risk to the public, doctors say
THURSDAY, Aug. 21, 2014 (HealthDay News) -- The two American health-care workers infected with the deadly Ebola virus while doing missionary medical work in West Africa have been released from the Atlanta hospital where they have been slowly recovering for several weeks, officials said Thursday.
Dr. Kent Brantly, 33, was released from Emory University Hospital Thursday morning.
Nancy Writebol left the hospital Tuesday. Her family said the 59-year-old woman is still weak and continues to recuperate at an undisclosed location, the Associated Press reported.
Emory doctors said both Brantly and Writebol are free of the virus and pose no risk to the public.
Brantly, looking gaunt, spoke at a Thursday morning news conference where he thanked his Emory medical team and the millions of people around the world who had prayed for him, USA Today reported. "Please do not stop praying for the people of West Africa," he said.
His wife Amber by his side, he called it "a miraculous day."
Brantly was working for the Christian aid group Samaritan's Purse, treating Ebola patients in Liberia when he fell ill. He and fellow aid worker Writebol were flown to Emory University Hospital early this month, where they were treated in an isolation unit.
Brantly and Writebol shouldn't endure long-term illness or disability because of their brush with the deadly virus, according to one of the United States' most experienced Ebola experts.
Dr. Joseph McCormick, regional dean of the University of Texas School of Public Health in Brownsville, told HealthDay that both aid workers most likely haven't endured any permanent organ damage or contracted a lasting chronic illness from the Ebola virus. And both should emerge from their struggle with immune resistance against future Ebola infection.
He said most survivors "get pretty much back to normal" over time, but admitted "this is something we know less about than we should."
McCormick is one of the very few U.S. physicians with first-hand experience with Ebola. As an officer with the U.S. Centers for Disease Control and Prevention, he belonged to the team that investigated the first Ebola epidemic in 1976, which occurred in the Congo, as well as the next two African outbreaks of Ebola.
Ebola victims who survive -- the virus kills 60 to 90 percent of those it infects -- first must deal with the loss of body mass caused by their illness, McCormick said.
"Over a period of two to three weeks, in addition to becoming physically very weak, they lose a lot of body mass," McCormick said earlier this month. "It's difficult for them to move around at all, and it takes some time for them to regain the ability to eat much."
Patients with Ebola experience terrible headaches plus body and muscle pain. "They have a tremendous sore throat, to the point where they cannot swallow their own saliva," he said.
There's not a lot that doctors could do for Brantly and Writebol, besides monitoring their vital statistics, providing pain medications, and encouraging them to eat and drink, McCormick said.
Both Brantly and Writebol received an experimental drug called Zmapp, but it's not known if the medication helped or whether they improved on their own, as can happen to some people with the disease. The treatment is so new it hasn't been tested in people, the Associated Press reported.
When both aid workers do make a full recovery, they likely will have one much-envied health advantage over most people, McCormick said -- a naturally acquired immunity to Ebola.
"They absolutely build up immune resistance," he said. "If I were out there right now running the program in West Africa, I would be looking for people who are far enough out of recovery that they feel well again. Those are the people I would be training to take care of patients, because they are the least likely to become reinfected."
The Ebola outbreak in West Africa has killed 1,350 people so far. Ebola cases have been reported in Guinea, Liberia, Sierra Leone and, to a lesser extent, Nigeria.
According to the World Health Organization (WHO), deaths are occurring most frequently in Liberia, which now accounts for at least 576 of the fatalities. Nearly 2,500 people have fallen ill across West Africa, which has now seen more infections during the current outbreak than in all of the previous two-dozen Ebola outbreaks combined, the APress reported.
Symptoms of Ebola include a sudden fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, poor kidney and liver function and, in some cases, both internal and external bleeding.
Unlike diseases such as tuberculosis or flu, Ebola isn't spread by breathing air from an infected person. Transmission requires direct contact with blood, secretions, organs or other body fluids of infected living or dead persons or animals, the WHO said.
More information
For more on Ebola virus, visit the U.S. Centers for Disease Control and Prevention ( ).
SOURCES: Joseph McCormick, M.D., regional dean, University of Texas School of Public Health, Brownsville; USA Today; Associated Press
by HealthDay staff

Health Tip: Help Keep Teen Drivers Safe

Frequently discuss auto safety
(HealthDay News) -- Inexperienced teen drivers, facing a host of potential distractions, are more likely than older people to be involved in an accident.
The U.S. Centers for Disease Control and Prevention offers these suggestions to help keep your teen safer:
Talk to him or her regularly about safe driving. Supervise your teen's driving for longer than the law requires. Establish clear rules of the road. Create a written agreement between you and your teen to follow these rules.
by HealthDay staff

Failing Vision Tied to Shorter Lifespans for Seniors

Link could be due to faltering ability to carry out daily tasks, researchers say
THURSDAY, Aug. 21, 2014 (HealthDay News) -- Among seniors, dimming vision may be tied to poorer survival, new research suggests.
The study involved more than 2,500 people, aged 65 to 84, who were assessed when they enrolled in the study and again two, six and eight years later.
Vision loss over time was associated with an increase in the person's risk of death during the study period, the researchers reported.
Although the study couldn't prove cause and effect, researchers led by Sharon Christ of Purdue University in West Lafayette, Ind., offered up some theories on the link between fading sight and shorter survival.
They believe the effect may be partly due to a sight-related decline in an individual's ability to perform basic daily tasks such as shopping, housework or using the telephone.
The risk of death among people who had difficulty with basic daily tasks rose by 3 percent a year over the study period, so that it was 31 percent higher by the end of the eight-year study.
People who had a vision decline of one letter size on an eye chart were expected to have a 16 percent increase in death risk during the study due to their declining ability to do basic daily tasks, the researchers said.
"Our findings have multiple implications. First, these findings reinforce the need for the primary prevention of visual impairment," the Purdue team concluded. "Moreover, the early detection of disabling eye diseases is suboptimal in the U.S. health care system, leading to otherwise preventable vision impairment".
"Finally, many Americans live with vision impairment that is correctable through the proper fitting of glasses or contact lenses," the researchers added.
The Purdue group also believes that the study reinforces the notion that if a senior is burdened by impaired sight, helping them complete everyday tasks may be important to maintaining long life.
The study was published online Aug. 21 in the journal JAMA Ophthalmology.
More information
The U.S. National Institute on Aging has more about eyes and vision ( ).
SOURCE: JAMA Ophthalmology, news release, Aug. 21, 2014
by HealthDay staff

Fewer U.S. Teens Using Sunscreen, Study Finds

Warnings about sun exposure and skin cancer aren't getting through, experts say
THURSDAY, Aug. 21, 2014 (HealthDay News) -- The number of U.S. teens using sunscreen dropped nearly 12 percent in the last decade, a new report shows.
During that same time period, the number of teens using indoor tanning beds barely decreased. Both indoor tanning and failure to use sunscreen increase the risk of skin cancers, including deadly melanomas, the researchers noted.
"Unfortunately, we found a decrease in the overall percentage of teens who reported wearing sunscreen, from 67.7 percent in 2001 to 56.1 percent in 2011," said lead researcher Corey Basch, an associate professor in the department of public health at William Paterson University in Wayne, N.J.
"Using sun-protective behaviors like applying sunscreen and avoiding intentional exposure to tanning devices will be key [to lowering cancer risk]," she added.
Use of indoor tanning devices by white girls decreased only slightly, from 37 percent in 2009 to 29 percent in 2011, she said.
The reasons for the decreased use of sunscreen among teens aren't clear, Basch said, but she thinks future research should focus on finding out why.
"High school years are important years that can impact the future," Basch said. "High school students are starting to make decisions for themselves. This research and other research suggest that adolescents continue to put themselves at risk."
The report was published in the August issue of Preventing Chronic Disease, a publication of the U.S. Centers for Disease Control and Prevention.
Dr. Jeanine Daly, a dermatologist at North Shore-LIJ Health System in Manhasset, N.Y., said she was surprised at the drop in sunscreen use despite all the warnings about UV exposure leading to skin cancer.
"It's still in vogue to have that suntanned color," she said.
Daly thinks that the message that sun exposure can lead to skin cancer is still not getting through, especially to young girls. "No matter how hard we've been trying to get that message out, we need to keep at it and work harder," she said. "The bottom line is that skin cancer is largely preventable."
The best sunscreens are those that protect against both UVA and UVB rays. "Both are involved in skin cancer," she said.
An effective sunscreen should contain a physical sunscreen such as zinc or titanium dioxide and a chemical sunscreen, she said. "The best sunscreen is one that contains zinc, because it covers both UVA and UVB rays," Daly said.
"The most important thing to remember about sunscreen is that it doesn't last very long," she added. Sunscreen needs to be applied every two hours, Daly said.
In addition, it takes a lot of sunscreen to be fully protected, Daly explained. "The average tube of sunscreen is usually only four to six ounces -- that should last maybe a day at the beach, but for a lot of people it lasts the entire season. We are just not using enough," she said.
For the study, researchers used the Youth Risk Behavior Surveillance System to collect data on the use of sunscreen and tanning devices from a sample of U.S. high school students.
More information
Visit the U.S. National Cancer Institute ( ) for more on skin cancer.
SOURCES: Corey Basch, Ed.D., M.P.H., associate professor, department of public health, William Paterson University, Wayne, N.J.; Jeanine Daly, M.D., dermatologist, North Shore-LIJ Health System, Manhasset, N.Y.; August 2014 Preventing Chronic Disease
by HealthDay staff

Getting Healthier a Big Money-Saver for People With Diabetes

Sticking with a fitness and nutrition plan can save more than $500 a year in health-care costs, study finds
THURSDAY, Aug. 21, 2014 (HealthDay News) -- Not only is eating better and exercising healthy for people with diabetes, it can save them hundreds of health-care dollars a year, a new study finds.
The study, led by Mark Espeland, a professor of public health sciences at Wake Forest Baptist Medical Center in Winston-Salem, N.C., included more than 5,100 overweight and obese type 2 diabetes patients.
Participants ranged in age from 45 to 76, and were randomly assigned to either an intensive "lifestyle change program" focused on diet and exercise, or to a standard diabetes support and education program.
The patients in the lifestyle group had higher levels of physical activity and maintained a lower body weight, resulting in better diabetes control, blood pressure, sleep, physical function and fewer symptoms of depression, the team reported.
There were financial savings, too. Over 10 years of follow-up, the patients in the lifestyle intervention group had 11 percent fewer hospitalizations and 15 percent shorter hospital stays. They also used fewer prescription medications than those in the diabetes support and education programs.
Those benefits led to an average savings of $5,280 in health-care costs per person over 10 years, or about $528 a year, according to the study published online Aug. 21 in the journal Diabetes Care.
The cost savings for people in the lifestyle intervention group were similar regardless of age, initial weight, gender or race, Espeland said.
"Type 2 diabetes is a chronic disease that is affecting more and more adults, increasing their health-care needs and costs," he added in a Wake Forest news release. "This study shows that by losing weight and being physically active, individuals can reduce these costs."
Two experts weren't surprised by the cost savings.
"It makes perfect sense that an intensive lifestyle intervention, focusing on weight loss and physical activity, would help control diabetes and reduce the cost of medications and complications related to type 2 diabetes," said Nina Eng, chief clinical dietitian at Plainview Hospital in Plainview, NY.
Dr. Gerald Bernstein is director of the diabetes management program at Mount Sinai Beth Israel in New York City. He said that once diabetes develops, costs soar. Patients must obtain medications plus blood sugar testing equipment and strips, and they often have diabetes-linked complications that involve hospitalizations and/or surgery.
Therefore, "it is not surprising that reducing weight will lower the cost of medical care for an individual if they have diabetes," Bernstein said.
More information
The U.S. Centers for Disease Control and Prevention has more about staying healthy with diabetes ( ).
SOURCES: Gerald Bernstein, M.D, director, diabetes management program, Friedman Diabetes Institute, Mount Sinai Beth Israel, New York City; Nina Eng, R.D, chief clinical dietitian, Plainview Hospital, Plainview, N.Y.; Wake Forest Baptist Medical Center, news release, Aug. 21, 2014
by HealthDay staff

Kids With Autism Have Extra Brain Connections, Study Says

Too many of these 'synapses' could be a problem, but medicines might someday help prune them away
THURSDAY, Aug. 21, 2014 (HealthDay News) -- Researchers report that children with autism appear to have excess synapses -- cellular connections -- in their brains compared with typical children.
The scientists also believe it might be possible to reduce the number of extra synapses through drug treatment.
Synapses are the points in the brain where brain cells (neurons) connect and communicate with each other. Having excess synapses may have a major impact on how the brain functions, theorized neuroscientists at Columbia University Medical Center in New York City.
The extra synapses in the brains of autistic children are due to a slowdown in the normal brain "pruning" process during development, the researchers believe.
"It's the first time that anyone has looked for, and seen, a lack of pruning during development of children with autism, although lower numbers of synapses in some brain areas have been detected in brains from older patients and in mice with autistic-like behaviors," study senior investigator, David Sulzer, a professor of neurobiology, said in a Columbia news release.
His team also found that rapamycin, an immunosuppressant that helps prevent rejection in organ transplants and coats some coronary stents, can restore normal synaptic pruning and improve autistic-like behaviors in mice. The effect was seen even when the drug was given to the mice after they developed those behaviors.
The drug causes side effects that might prevent its use in people with autism, the researchers said. However, "the fact that we can see changes in behavior suggests that autism may still be treatable after a child is diagnosed, if we can find a better drug," Sulzer added.
For the study, he and his colleagues examined 26 brains of youngsters with autism -- 13 aged 2 to 9, and 13 aged 13 to 20. All of the children had died from causes other than autism. Their brains were compared to 22 autopsied brains of children without autism.
The researchers measured "synapse density" in a small section of tissue in each brain. By late childhood, synapse density fell by about half in the brains of children without autism, but fell only 16 percent in the brains of those with autism.
The researchers also found clues about what causes the pruning defect in the brains of children with autism, according to the study, which was published online Aug. 21 in the journal Neuron.
More information
There's more on autism at the U.S. National Institute of Neurological Disorders and Stroke ( ).
SOURCE: Columbia University Medical Center, news release, Aug. 21, 2014
by HealthDay staff

Low Birth Weights May Put Black Women at Risk for Diabetes

Study found association regardless of their current weight
THURSDAY, Aug. 21, 2014 (HealthDay News) -- Being born at a low birth weight puts black women at increased risk for type 2 diabetes, a new study suggests.
The findings may partly explain high diabetes rates among black Americans, a population that has a high prevalence of low birth weight, the researchers added.
Their study of more than 21,000 black women found that those with a low birth weight were 13 percent more likely to develop type 2 diabetes than those with a normal birth weight. The risk of diabetes was 40 percent higher in those with a very low birth weight.
Low birth weight was defined as less than 5.5 pounds and very low birth weight as less than 3.3 pounds.
A woman's body weight did not appear to affect the link between low birth weight and increased diabetes risk. Those who weren't obese still had a higher risk of diabetes if they had a low or very low birth weight.
While the study found an association between birth weight and diabetes risk, it did not prove a cause-and-effect link.
The researchers pointed to two possible reasons for the association: When a newborn body lacks nutrition, it reprograms itself so it can absorb more of what nutrition it does get and that could raise the risk for diabetes later in life; and certain gene mutations may affect the body's ability to make insulin, which would lead to a low birth weight and an increased chance for diabetes in adulthood.
The study was published Aug. 21 in the journal Diabetes Care.
"African-American women are at increased risk of developing type 2 diabetes, and also have higher rates of low birth weight than white women," Edward Ruiz-Narvaez, an assistant professor of epidemiology at Boston University School of Public Health, said in a university news release.
"Our study shows a clear relationship between birth weight and diabetes that highlights the importance of further research for this at-risk group," he added.
More information
The U.S. National Library of Medicine has more about type 2 diabetes ( ).
SOURCE: Boston University, news release, Aug. 21, 2014
by HealthDay staff

New Drug May Fight Serious Respiratory Virus in Infants

RSV leading cause of hospitalization among infants, researchers note
THURSDAY, Aug. 21, 2014 (HealthDay News) -- An experimental drug shows promise in treating respiratory syncytial virus (RSV), a leading cause of pneumonia in infants, researchers report.
"We are finally making major progress in being able to treat human RSV infections -- the world's second leading cause of serious viral pneumonia, second only to influenza virus," said study author Dr. John DeVincenzo, a professor of pediatrics at the University of Tennessee College of Medicine in Memphis.
"There is no current treatment or vaccine for RSV pneumonia, and so patients were previously forced to get over the virus by themselves," he said. RSV is the leading cause of hospitalization among infants in the United States, the researchers noted.
In this small study of 140 adults, the drug, dubbed GS-5806, reduced the amount of the virus in the systems of those who received the medication.
"For the first time, we showed that once we reduce the amount of virus in patients, they very quickly started to feel better," DeVincenzo said.
Moreover, the drug appeared safe and easy to give, he said.
DeVincenzo noted that infants, the elderly and people with lung conditions and immune system problems are those most at risk for RSV. "The virus can cause severe disease, hospitalization and death in these populations," he said.
The finding paves the way for this new antiviral medicine to be tried in those groups of people, DeVincenzo added.
The report was published Aug. 21 in the New England Journal of Medicine.
Dr. Otto Ramos, an infectious disease specialist at Miami Children's Hospital, said, "I think this is promising. Obviously, this is just the first step of one in many."
How well it will work in children and how well it is tolerated is still an unanswered question, he noted. "Whether it is going to have the same effect is yet to be determined," Ramos said.
For the study, DeVincenzo and colleagues tried GS-5806 on healthy adults who had been infected with RSV. The drug was given in varying doses to 87 of 140 participants, while the others received an inactive placebo.
DeVincenzo said that the drug was first tried on adults because of ethical issues surrounding the purposeful infection of volunteers in the trial.
"Babies and certain other populations, including the mentally disabled, cannot weigh risks and benefits fully and therefore cannot be asked to participate in a trial of a medicine that is experimental, and that there is not clear evidence of benefit to themselves personally," he said. "Competent adults can choose to accept risk to themselves based on purely an altruistic potential future benefit to mankind."
Almost all medicines developed for children are first developed for adult diseases and then given to children once the drug's safety and efficacy are established, DeVincenzo explained.
"However, there are some diseases of infants and children which do not have a clear parallel disease in adults," he said. "RSV is one of these pediatric-specific diseases. For this and other reasons, we first showed that we could safely infect adults with the virus that caused a similar, though much milder, disease in these adults. Then we treated these experimentally infected adults with our newly discovered antiviral drug."
Side effects of the treatment were mild, DeVincenzo noted. "There were a small number of laboratory tests that became abnormal during the therapy. These laboratory abnormalities are commonly seen in many types of medications, and were a small drop in the white blood [cell] count and mild elevations in liver enzymes, which are routinely measured for safety assessments," he said.
Based on this trial, DeVincenzo said trials of the drug in infants and in the elderly are being planned.
The study was funded by Gilead Sciences, maker of GS-5806.
More information
Visit the U.S. Centers for Disease Control and Prevention ( ) for more on RSV.
SOURCES: John DeVincenzo, M.D., professor of pediatrics, University of Tennessee College of Medicine, Memphis; Otto Ramos, M.D., infectious disease specialist, Miami Children's Hospital; Aug. 21, 2014, New England Journal of Medicine

My Health Patient Portal